Management of Congenital Nasolacrimal duct Obstruction

Dr. Rajat Maheshwari

Epiphora from the Greek meaning downpour refers to
overflow of tears down the face and does not
distinguish between hyper secretion and outflow
obstruction.
Epiphora in context to this article refers to obstruction
of the lacrimal drainage system.
Obstruction of the nasolacrimal drainage system is
extremely common in pediatric age group, occurring
in as many as 30% of new borns.
The article reviews the management of a child with
epiphora.
Evaluation

Figure 2: Child with nasolacrimal duct obstruction in right eye.

Observation is a simple and reliable tool with the

clinician. The level of tears, position of puncta, lids
and eyelashes should be noted. Obstruction of the
tear drainage system can be acquired or congenital,
it is important to rule out acquired causes of tearing
such as corneal, lid or lash abnormalities. Lacrimal
obstruction problems can be divided as related to upper
(puncta to lacrimal sac) or lower (sac to the opening
of the nasolacrimal duct) system (Fig 1).

Dye Disappearance test.

Instill single drop of 2% fluorescein into the
anesthetized conjunctival cul-de-sac. Excess fluid is
wiped out and the tear meniscus is observed over a
5min period. In a normal eye the tear meniscus will
become relatively unstained within 5 minutes, where
as when lacrimal obstruction is present, the stained
meniscus either will increase or be diluted only shortly.
Lower system block (Dacryostenosis).

3 to 5 mm
Fundus of sac
10 mm
Body of sac

2 mm
Vertical part
8 mm
Horizontal
part

12 mm
Interosseous
part
5 mm
Meatal part

Nasolacrimal
duct

Canaliculus
20 mm
Inferior
meatus

Inferior turbinate
Inferior turbinate

Figure1: Normal anatomy of the nasolacrimal system.

In children, parents provide information about the

amount of tearing, whether constant or intermittent,
and the type of regurgitation. Expression of mucoid
material through the puncta on pressure over the
lacrimal sac confirms the diagnosis of congenital
nasolacrimal duct obstruction (Fig 2). Dye
disappearance test is a quick and easy test to confirm
the diagnosis of nasolacrimal duct obstruction.

Dacryostenosis or atresia of the nasolacrimal duct is

the most common cause of epiphora in the pediatric
population. It is thought to result from failure of
canalization of the nasolacrimal duct. The most
common site is at the mucosal entrance at the inferior
meatus in the nose. The obstruction can be either
membranous or osseous. Other rare causes can be
migration of the duct to an abnormal passage.
Treatment
Dacryostenosis should be managed conservatively
whenever possible. Traditional approach has been to
combine massage of the nasolacrimal sac and duct
with topical antibiotic.
Parents should be carefully instructed as to how to
perform massage properly. It is better to demonstrate
the technique of massage to the mother. It is advisable
to place one forefinger over the medial canthal area
on the inferior part of the anterior lacrimal crest and
slide the finger in an inferior direction, placing
moderate pressure over the lacrimal sac and

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45

nasolacrimal duct. I recommend 20 to 25 strokes three

times daily. An antibiotic ointment can also be used
which also acts as a lubricant.

knowledge of the anatomy of the lacrimal system is

necessary, so that at any given time one is aware of
the path the probe is taking.

Conservative management is continued until epiphora

resolves, tearing persists beyond 12 months of age,
no improvement for 3-4 months or recurrent infections
and anxious parents.

I perform all probing under general anesthesia and

feel this is safer and comfortable to both the patient
and surgeon. A Bowmans 00 (0.90mm) or 0 (1.00mm)
probe has the

Probing

right diameter and stiffness for pediatric use. Wider

diameter probes are hazardous because they can
cause trauma to the puncta or canaliculus. I prefer to
probe from the upper canaliculus, a location that makes
it easier to turn from the lacrimal sac to the
nasolacrimal duct (Fig 3, 4). One important landmark
is to feel the hard touch of the medial wall of the sac
before making the turn. Once the probe is in the
nasolacrimal duct it is passed until the resistance is
felt. Once the probe is entered in the canaliculus, it is
passed till the hard feel of the medial wall of the
lacrimal fossa is felt, at this time the probe is turned
to enter the nasolacrimal duct and gently advanced

Probing of the nasolacrimal duct system is a standard

procedure in the management of congenital
nasolacrimal duct obstruction. However, the timing for
initial probing has been a matter of controversy. I
personally defer probing until the childs first birthday.
This is based on earlier studies, which report a high
rate of spontaneous resolution in the first year of life.
The best data on the subject is from McEwen and
Young who did a
Prospective study in a Scottish community in 1988. A
cohort of 4792 children born during one calendar year
were observed, and 942 (20%) had evidence of
defective lacrimal drainage system at some time
during there first year of life. By the age, one 930
(98.72%) children had cleared their obstruction. Any
decision to probe before one year should take this
high rate of spontaneous resolution into account.
However, recurrent infection and discharge and the
attendant lid irritation may occasionally prompt the
decision to probe early, as the need for anesthesia at
an early date for some other procedure.
Another major point of debate is whether to probe
infants in the office or under general anesthesia in a
hospital setting. This primarily applies to initial probing
procedures. The most important concern is the risk of
general anesthesia for small children. For straight
forward nasolacrimal duct obstruction, it is
unnecessary to perform probing in patients younger
then 6 months of age; therefore with increasing
availability of good anesthetic facility, I personally
recommend probing to be done under general
anesthesia.

Figure 3: Dilatation of the upper puncta with punctum dilator.

It is difficult to attempt probing and irrigation of the

infant in office setting and for obvious reasons has a
high risk of traumatizing the lacrimal passage.
The technique of probing an infants nasolacrimal
system must be gentle because of the delicate punctum
and canaliculus. As this is a blind procedure, good

Figure 4: Bowmans probe is passed gently in the direction of the

canaliculus; note that the lid is pulled laterally to straighten the
canaliculus, thus avoiding any false passage.

46

Journal of the Bombay Ophthalmologists Association

Vol. 14 No. 1

till resistance is felt. The breaking of the membrane is

felt as the probe advances the obstruction (Fig 5).
There are two types of obstructions encountered
during probing, simple and complex. In simple
obstruction the resistance is easily bypassed with the
help of Bowmans probe and post, probing syringing
reveals a patent lacrimal system. While in complex
obstruction the probe is not bypassed and there is
firm resistance to the passage of the probe. Post

Figure 6: The upper puncta is blocked with punctum dilator and

fluorescein colored saline is pushed from the lower puncta. Flow
of fluorescein colored saline confirms the patency of the system.

irrigation but in the post operative period again closes.

This is

Figure 5: After the hard touch of the medial wall of the sac, the
probe is directed downward, backward and medially in the direction of the nasolacrimal duct.

probing syringing is not patent in these patients. The

patency of the nasolacrimal system checked by
obstruction of the upper puncta by punctum dilator
and irrigation of saline from the lower puncta.
The saline is colored with sterile fluorescein strip. Flow
of saline in the throat is confirmed by placement of
pediatric size suction catheter in the throat and
passage of flourescein stained saline through it (Fig
6). Only a small amount of saline is required to ensure
the free flow of saline, also small amount is less likely
to cause laryngospasm or aspiration if the procedure
is performed under ketamine anesthesia. Each patient
receives antibiotic drops four times daily for three
weeks. The patient is seen again after 1-2 week. The
results at first follow up are suggestive of the outcome
of the procedure. Subsequent follow up is at 1, 3 and
6 months. Those who cannot come for follow up can
be enquired about any recurrence of symptoms.
Failed probing
Patients with failed probing can be divided into 3 groups.
In the first group, there is a complex type of obstruction,
which prevents the passage of probe beyond the
obstruction. The second group is one that opened with
probing and showed patency of the passage on saline

often associated with a laterally displaced inferior

turbinate bone compromising the opening of the
inferior meatus. I personally have no experience on
turbinate in fracture, but in this procedure, the inferior
turbinate bone is rotated medially and superiorly,
causing an increase in the space in the inferior meatus.
The third group comprises children who underwent
probing elsewhere, and there is uncertainty of the
adequacy of the procedure or details of the anatomy
as revealed by the first attempt. Repeat probing can
be performed after an interval of two to three months.
Pediatric Dacryocystorhinostomy
Dcaryocystorhinostomy in pediatric age group is not
as predictive as in adults due to developmental changes
and vigorous response to healing. There are few
published reports of DCR in pediatric patients. The
poorly defined and rapidly changing anatomy, along
with tendency for scar formation is challenging for
the managing physician. The reported success rate of
major lacrimal surgery in children has ranged from
78.9% to 96% in various studies. In a large series of
1060 external dacryocystorhinostomy performed by
the author, 35 (3.30%) were in pediatric patients with
a success rate of 97.2% (mean follow up 4.6 months).
The first attempt is the one most likely to succeed, so
should be done with proper technique and by an
experienced lacrimal surgeon.
My surgical technique for pediatric DCR is same as for
adults. I perform the surgery under microscope, to
give a better view of the surgical site. The skin incision

April 2005
is 10-12mm over the anterior lacrimal crest below
the medial palpebral ligament thus preserving the
attachments at the medial canthus. A large osteotomy
and good mucosal anastomosis of the anterior flaps
of the lacrimal sac and nasal mucosa ensures good
surgical results. Intubation for pediatric DCR is again
a matter of individual preference. The superior and
inferior canaliculi are separately intubated and the
probe is retrieved from below the inferior turbinate.
Once the nasolacrimal duct is intubated, the tubes
are fixed in the nose. The recommended time for
removal of tube is between 3-6 months. I
Personally do not intubate my cases of external DCR
and the high success rate without silicone intubations
suggest that routine intubation is not required for
pediatric DCR.
I prefer nasal decongestants one day before surgery
and continue for 2 days in the postoperative period
along with systemic and topical antibiotics for all
pediatric patients.
Summary
Epiphora in pediatric patients is a common problem
and requires a detail check up to rule out other causes
of watering in children. Congenital nasolacrimal duct
obstruction can be managed by conservative methods
in most patients until the first year of life. A congenital
dacryocele is an exception and should be probed with
in the first few weeks of life.
If tearing persists beyond 12 months of age, probing
under general anesthesia should be performed. If
probing is unsuccessful depending upon the type of
obstruction it can be tried again after an interval of 68 weeks. Dacryocystorhinostomy is indicated in cases
with failed probing and complex lower system
obstruction and the surgery can be performed in
children at around 4 years of age with high success
rate.

47
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Kenneth L. P, James A. K. Treatment of

Congenital Nasolacrimal duct Obstruction.
Ophthalmology Clinics of North America 1991;
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2.

Robert C K. Congenital lacrimal abnormalities in

Principles and Practice of Ophthalmic Plastic and
Reconstructive Surgery. W B Saunders Company;
1996. Vol 2, p 731-747.

3.

William T, Edward A J. Lacrimal drainage

surgery . Duanes Clinical Ophthalmology.
Lippincott-Raven publishers. 1997; vol 6, 124.

4.

Welhem R, Higes SM. Lacrimal surgery in

children. Am J Ophthalmol 1985; 99:27-34

5.

Hakin KN, Sullivan TJ, Sharma A, Welham RAN.

Pediatric dacryocystorhinostomy. Aust N Z
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Nowinski TS, Flanagan JC, Mauriello J. Pediatric

dacryocystorhinostomy . Arch Ophthalmol
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7.

Eric AB, Yassir A, Geoffrey ER. Pediatric

dacryocystorhinostomy for nasolacrimal duct
obstruction Ophthalmology 2001; 108:15621564.

Contact Details :
Dr. Rajat Maheshwari
Faculty
Cataract, Orbit, Lacrimal & Eyeplastic Serivce
Shri Ganapati Netralaya,
Jalna 431203.
Maharashtra State.